Healthcare Provider Details

I. General information

NPI: 1326109125
Provider Name (Legal Business Name): DAVID TRAVIS REILLY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N. HOWARD
FRESNO CA
93701-2214
US

IV. Provider business mailing address

4910 E CLINTON WAY SUITE 101
FRESNO CA
93727-1560
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-7300
  • Fax: 559-459-3750
Mailing address:
  • Phone: 559-453-5200
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16367
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 16367
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA16367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: